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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701438
Report Date: 09/17/2024
Date Signed: 09/17/2024 11:47:08 AM


Document Has Been Signed on 09/17/2024 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GREEN BELL CARE HOME INCFACILITY NUMBER:
342701438
ADMINISTRATOR:NAMJUNG CHOFACILITY TYPE:
740
ADDRESS:12798 MISSION PEAK WAYTELEPHONE:
(916) 467-5900
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY:6CENSUS: 0DATE:
09/17/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Namjung ChoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived announced to conduct a pre-licensing inspection. LPA Valerio met with Licensee/Administrator Namjung Cho, and explained the purpose of the visit.

The facility is licensed to serve individuals 60 years of age and older. Fire Clearance granted for 6 non-ambulatory, master bedroom approved as staff room only, room behind living room approved as staff room only. The facility LPA Valerio and Administrator toured the facility to ensure compliance with Title 22 regulations. Resident bedrooms were fully furnished, clean, and organized. Resident bathrooms were fully stocked and equipped with a shower chair, hand rails, trash can, hand soap, and paper towels. Common areas were fully furnished. LPA observed where staff files, resident files, and medications will be stored. All cabinets were equipped with locks to ensure sharps, chemicals, and medications were locked and inaccessible to residents in care. The facility was observed to have a pantry with food items, a refrigerator and freezer for perishable and non-perishable food items. The backyard exterior area had an area for outdoor visitation, gardening area, and outdoor activities. No health and safety concerns were observed.

Pre-Licensing is complete and this facility has no deficiencies. Component III was completed. No further questions.

An exit interview was held, and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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